Type 2 diabetes – all change
The latest National Institute for Health and Care Excellence (NICE) guidelines, out today, are for the management of type 2 diabetes – and they’ve been a long time coming.
Three years ago, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) produced new guidelines for type 2 diabetes, with a major shift in focus towards personalised care and targets. Gone was the ‘one size fits all’ target – the new guidelines were all about taking the whole person into account, especially where blood glucose control was concerned. Now the new NICE guidelines have followed suit. In fact, whether you live in the UK or the USA, pretty much every recommendation is the same now.
Keeping your blood glucose well controlled if you have diabetes is hugely important to reduce the risk of complications – heart attack and stroke levels are improving, but they are still by far the biggest killers among people with type 2 diabetes. And blood glucose, as well as cholesterol and blood pressure control, are key. High blood glucose is particularly toxic to the eyes, the kidneys and the nerves.
But high blood sugar takes many years to do really serious damage. And too-tight glucose control can sometimes do more harm than good. So the focus now is not just on good control, but on whether you fall into a ‘high-risk’ category where ‘good enough’ control is better than ‘perfect’. These high-risk categories include people who:
- Are older and frail
- Take lots of medicines that could interact with glucose-lowering ones
- Are at risk of falls
- Suffer from lots of other medical conditions
- Are at higher risk of the consequences of sudden drop in blood sugar, called ‘ hypos’
- Drive or operate heavy machinery
- Have lost the ability to recognise early warning symptoms of ‘hypos’
Here are some of the key headlines for medicines and targets other than glucose control:
1) Aspirin is out for most people. If you have type 2 diabetes and haven’t had a heart attack or stroke, it’s no longer recommended that you take a 75 mg aspirin tablet every day
2) Your blood pressure should be below 140/80 mm Hg (millimetres of mercury) unless you have evidence of complications affecting your eyes, kidneys, heart of brain, in which case it should be below 130/80
3) Keeping your cholesterol levels down is still important, but targets will depend on whether you’ve had a heart attack.
For blood glucose targets, there’s quite a lot of tweaking. The measurements used are HbA1c – which gives an average of your blood glucose over the last few weeks. As a standard rule, the recommendations are that:
1) When you’re first diagnosed, you should be aiming for an HbA1c below 48 mmol/mol
2) If your level rises despite diet and lifestyle changes, you should start taking a medicine called Metformin (unless there’s a good medical reason you can’t)
3) If you haven’t started medication yet or you’re taking metformin, you should aim for an HbA1c below 48 mmol/mol
4) If your level rises on metformin to above 58 mmol/mol, your doctor and you should
5) If you’re on two medicines and your HbA1c rises above 58 mmol/mol, your doctor and you should
But don’t forget, all these targets are going to be personalised – so if you have other medical complications, your doctor may want to discuss levels that are best suited for you. Likewise, your doctor should be outlining all the drug options for you, so you can decide together which one is best for you.
Another really positive change as far as I and many other doctors are concerned is the move away from older drugs like sulfonylureas such as
Instead, the new guidelines offer a range of options as
The last big focus of the new guidelines is on helping the patient take control. No matter how dedicated your medical team, they’re only there for a tiny proportion of your life. Taking charge of your own diet, lifestyle and weight